Wednesday, December 02, 2009

The tenth anniversary of “To Err is Human”

Although I've written several posts this year about the past decade of the patient safety movement the official tenth anniversary of the IOM report was yesterday. Bob Wachter has just written a post and an article on the subject. So it's time to reflect again.

Whether or not the IOM report marked the beginning of the patient safety movement it did raise the intensity of the conversation. When I started as a hospitalist, ten months before the report came out, we were already concerned about safe practices. The movement to address medical errors head on, thanks to the work of Albert Wu and others, was already well under way. Efforts to address fatigue and sleep deprivation in house officers was in high gear due to the Libby Zion case a decade and a half earlier.

So what happened after the report? Two things right off the bat. First, “medical error” was redefined to encompass almost all bad outcomes, setting the stage for Medicare's ill conceived never-events policy, a giant step backward in tort reform and, as a result, an undermining of the cause of transparency. Second, “patient safety”, though not a new concept, became a magical phrase. If you were advocating for process change, no matter how weak your argument, you only needed to add “this is a patient safety issue” to give it teeth.

Maybe I was naïve when the report came out. I envisioned a new level of transparency that would cut through all the layers of finger-pointing, defensiveness and institutional BS to help us tackle errors and bad outcomes head on. But that level of transparency was predicated on a blame free culture, one that never had a chance to develop.

So Bob gives patient safety, a decade after the IOM report, a B-. Was I too harsh in giving it a failing grade? It's all pretty subjective, but Bob, in his article, did break it down into component parts. I won't attempt to parse it here (everyone with an interest in this field should read the entire article) aside from a few observations. We have more systems in place to address patient safety, including regulatory and reporting systems. Health information technology has failed to live up to its promise, but with the proper tweaks it could be leveraged to make a real difference in the next decade. Many process improvements have been adopted without supporting evidence. Some (hand washing) are no-brainers which should be pushed for wider adoption. Others (rapid response teams) may be little more than cosmetic.

Finally, we have no data on the overall effect of the patient safety movement on outcomes. My own view is that hospitalized patients are far better off now than they were 30-40 years ago due to decades of progress in technology, pharmaceuticals and evidence based medicine.

So, while I agree that due to some systems now in development we may be on the cusp of real progress I remain very skeptical, and largely negative, about the effects of the IOM report. In his paper Bob cites the Harvard Medical Practice study, which the IOM drew on to raise awareness of medical mistakes. What Bob didn't mention was that one of the authors of that study harshly criticized the IOM for misinterpreting his data in a NEJM editorial, four months after the report, entitled The Institute of Medicine Report on Medical Errors — Could It Do Harm? Those words were prescient! (It never ceases to astonish me how, in all the self-congratulatory writings on patient safety, that editorial is repeatedly ignored).

So Bob and many others think the IOM's hype of medical mistakes is a good thing. Here's a section of his post:

In Internal Bleeding, after describing the history of the IOM (founded in 1970 as the National Academy of Science’s think tank for healthcare issues) and the fact that the venerable organization was not exactly known for its eye-popping PR, Kaveh Shojania and I wrote:

So one could not help but be taken aback by the screaming headlines that leapt off the book jacket of the [IOM Report]. One part Constitution Avenue to three parts Madison Avenue, its tone instantly caught the attention of the general populace and the media. Just consider the breathless prose of the book jacket, more like the trailer for a Hollywood blockbuster than the synopsis of an academic report:

Experts estimate that as many as 98,000 people die in any given year from medical errors that occur in hospitals. That’s more than die from motor vehicle accidents, breast cancer, or AIDS—three causes that receive far more public attention…. This volume reveals the often-startling truth of medical error and the disparity between the incidence of error and public perception of it…

As if that wasn't enough pizazz, the authors converted the staggeringly large but potentially bloodless “44,000-98,000 deaths per year” figure into the now-famous “Jumbo Jet Units” – making the point that the number of deaths from medical mistakes was the equivalent of a large plane crashing every day.

Although some have critiqued the "crash-a-day" spin as hyperbolic, I continue to believe it was masterful. Something was necessary to shake us out of our collective inattention, and it took the Jumbo Jet analogy to do it.

That's precisely what I think was wrong with the report. Should we be basing public policy and medical decisions on spin? It was pure and simple grandstanding, and a perfect example of the harm that can be done when adjudication of scientific issues is turned over to popular debate. While some would argue that the end justifies the means we have no evidence that the IOM report helped patients.

What does the next decade hold? Hospitalized patients will continue to be better off as medicine advances, but we need to reform our culture of blame before we can really tackle patient safety head on.

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